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Nielsen JB, Kristiansen IS, Thapa S. Prolongation of disease-free life: When is the benefit sufficient to warrant the effort of taking a preventive medicine? Prev Med 2022; 154:106867. [PMID: 34740678 DOI: 10.1016/j.ypmed.2021.106867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 10/21/2021] [Accepted: 10/30/2021] [Indexed: 11/18/2022]
Abstract
The prolongation of disease-free life (PODL) required by people to be willing to accept an offer of a preventive treatment is unknown. Quantifying the required benefits could guide information and discussions about preventive treatment. In this study, we investigated how large the benefit in prolongation of a disease-free life (PODL) should be for individuals aged 50-80 years to accept a preventive treatment offer. We used a cross-sectional survey design based on a representative sample of 6847 Danish citizens aged 50-80 years. Data were collected in 2019 through a web-based standardized questionnaire administered by Statistics Denmark, and socio-demographic data were added from a national registry. We analyzed the data with chi-square tests and stepwise multinomial logistic regression. The results indicate that the required minimum benefit from the preventive treatment varied widely between individuals (1-week PODL = 14.8%, ≥4 years PODL = 39.2%), and that the majority of individuals (51.1%) required a PODL of ≥2 years. The multivariable analysis indicate that education and income were independently and negatively associated with requested minimum benefit, while age and smoking were independently and positively associated with requested minimum benefit to accept the preventive treatment. Most individuals aged 50-80 years required larger health benefits than most preventive medications on average can offer. The data support the need for educating patients and health care professionals on how to use average benefits when discussing treatment benefits, especially for primary prevention.
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Affiliation(s)
- Jesper B Nielsen
- Research Unit of General Practice, University of Southern Denmark, J.B. Winsløws Vej 9, 5000 Odense, Denmark.
| | - Ivar S Kristiansen
- Research Unit of General Practice, University of Southern Denmark, J.B. Winsløws Vej 9, 5000 Odense, Denmark; Department of Health Management and Health Economics, University of Oslo, Norway.
| | - Subash Thapa
- Research Unit of General Practice, University of Southern Denmark, J.B. Winsløws Vej 9, 5000 Odense, Denmark.
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Røssell EL, Bornhøft LO, Lousdal ML, Støvring H. Predicting difference in mean survival time from cause-specific hazard ratios for women diagnosed with breast cancer. Eur J Public Health 2021; 31:597-601. [PMID: 33462621 DOI: 10.1093/eurpub/ckaa252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Relative reduction in breast cancer mortality is the preferred outcome measure for evaluation of mammography screening. However, mean survival time has been advocated as a better and more intuitive outcome for risk communication. We have previously introduced a method to predict difference in mean survival time from empirical hazard ratios for all-cause mortality. In this article, we aim to investigate the association between hazard ratios for breast cancer mortality and the difference in mean survival time for women diagnosed with breast cancer. METHODS We retrieved data on all women diagnosed with first-time invasive breast cancer in Norway from 1960 through 2004. Women were followed until emigration or end of follow-up on 31 December 2015, whichever came first. Observed differences in mean survival times and hazard ratios for both breast cancer death and death from causes other than breast cancer were obtained for neighbouring time periods defined by women's age and year of diagnosis. Based on previously developed methods, we fitted a linear relationship between observed differences in mean survival and logarithmic hazard ratios. RESULTS A linear association was found between breast cancer-specific hazard ratios and difference in mean survival time for women diagnosed with breast cancer. This association was also estimated with adjustment for other causes of death than breast cancer. CONCLUSIONS The change in mean survival time could be predicted from an estimated reduction in breast cancer mortality. This outcome measure can contribute to better and more understandable risk information about the effect of mammography screening programmes.
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Affiliation(s)
- Eeva-Liisa Røssell
- Department of Public Health, Health Promotion and Population Health, Aarhus University, Aarhus C, Denmark
| | - Laura O Bornhøft
- Department of Public Health, Health Promotion and Population Health, Aarhus University, Aarhus C, Denmark
| | - Mette Lise Lousdal
- Department of Public Health, Epidemiology, Aarhus University, Aarhus C, Denmark
| | - Henrik Støvring
- Department of Public Health, Health Promotion and Population Health, Aarhus University, Aarhus C, Denmark
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Bonner C, Trevena LJ, Gaissmaier W, Han PKJ, Okan Y, Ozanne E, Peters E, Timmermans D, Zikmund-Fisher BJ. Current Best Practice for Presenting Probabilities in Patient Decision Aids: Fundamental Principles. Med Decis Making 2021; 41:821-833. [PMID: 33660551 DOI: 10.1177/0272989x21996328] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Shared decision making requires evidence to be conveyed to the patient in a way they can easily understand and compare. Patient decision aids facilitate this process. This article reviews the current evidence for how to present numerical probabilities within patient decision aids. METHODS Following the 2013 review method, we assembled a group of 9 international experts on risk communication across Australia, Germany, the Netherlands, the United Kingdom, and the United States. We expanded the topics covered in the first review to reflect emerging areas of research. Groups of 2 to 3 authors reviewed the relevant literature based on their expertise and wrote each section before review by the full authorship team. RESULTS Of 10 topics identified, we present 5 fundamental issues in this article. Although some topics resulted in clear guidance (presenting the chance an event will occur, addressing numerical skills), other topics (context/evaluative labels, conveying uncertainty, risk over time) continue to have evolving knowledge bases. We recommend presenting numbers over a set time period with a clear denominator, using consistent formats between outcomes and interventions to enable unbiased comparisons, and interpreting the numbers for the reader to meet the needs of varying numeracy. DISCUSSION Understanding how different numerical formats can bias risk perception will help decision aid developers communicate risks in a balanced, comprehensible manner and avoid accidental "nudging" toward a particular option. Decisions between probability formats need to consider the available evidence and user skills. The review may be useful for other areas of science communication in which unbiased presentation of probabilities is important.
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Affiliation(s)
- Carissa Bonner
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia.,ASK-GP NHMRC Centre of Research Excellence, The University of Sydney, Australia
| | - Lyndal J Trevena
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia.,ASK-GP NHMRC Centre of Research Excellence, The University of Sydney, Australia
| | | | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA.,School of Medicine, Tufts University, USA
| | - Yasmina Okan
- Centre for Decision Research, University of Leeds, Leeds, UK
| | | | - Ellen Peters
- Center for Science Communication Research, University of Oregon, Eugene, OR, USA
| | - Daniëlle Timmermans
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, North Holland, The Netherlands
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Hansen MR, Hróbjartsson A, Videbæk L, Ennis ZN, Pareek M, Paulsen NH, Broe M, Olesen M, Pottegård A, Damkier P, Hallas J. Postponement of Death by Pharmacological Heart Failure Treatment: A Meta-Analysis of Randomized Clinical Trials. Am J Med 2020; 133:e280-e289. [PMID: 32173347 DOI: 10.1016/j.amjmed.2019.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/02/2019] [Accepted: 11/03/2019] [Indexed: 10/24/2022]
Abstract
BACKGROUND Outcome postponement has been proposed as an effect measure for preventive drug treatment. It describes the average delay of the investigated unwanted clinical event, achieved by taking medication. The objective was to estimate postponement of death for the following heart failure medications compared to placebo: beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), ARB added to ACE inhibitors, aldosterone antagonists, ivabradine, and renin antagonists. METHODS We searched Medline and Embase from inception of databases until October 2017. Eligibility criteria were randomized placebo-controlled heart failure trials, including at least 1000 participants, with survival as a prespecified outcome and a minimum trial duration of 1 year. We calculated the outcome postponement by modeling the area between survival curves. This area was modeled on the basis of the hazard ratio or relative risk, the rate of mortality in the placebo group, and the trial duration. All results were standardized to a 3-year trial duration to ensure comparability between treatments. RESULTS We identified 14 eligible trials, with a total of 52,014 patients. The results in terms of postponement of all-cause mortality was: beta-blockers 43.7 days (95% confidence interval [95% CI], 20.8-66.5), ACE inhibitors 41.0 days (95% CI, 18.8-63.3), and aldosterone-antagonists 41.3 days (95% CI, 14.3,68.4). CONCLUSION The modeled outcome postponement estimates reiterate beta-blockers, ACE inhibitors, and aldosterone antagonists as the mainstay of heart failure treatment. Furthermore, ivabradine or ARBs added to ACE inhibitors results in no statistically significant gain in survival.
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Affiliation(s)
- Morten Rix Hansen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark; Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark; Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark.
| | - Asbjørn Hróbjartsson
- Center for Evidence-Based Medicine, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Odense Explorative Patient Data Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Lars Videbæk
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Zandra Nymand Ennis
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Manan Pareek
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark; Department of Cardiology, North Zealand Hospital, Hillerød, Denmark; Department of Internal Medicine, Yale New Haven Hospital, New Haven, Conn
| | - Niels Herluf Paulsen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Martin Broe
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Morten Olesen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark; Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
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Postponement of Death by Statin Use: a Systematic Review and Meta-analysis of Randomized Clinical Trials. J Gen Intern Med 2019; 34:1607-1614. [PMID: 31073857 PMCID: PMC6667545 DOI: 10.1007/s11606-019-05024-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 10/12/2018] [Accepted: 03/21/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The average postponement of the outcome (gain in time to event) has been proposed as a measure to convey the effect of preventive medications. Among its advantages over number needed to treat and relative risk reduction is a better intuitive understanding among lay persons. OBJECTIVES To develop a novel approach for modeling outcome postponement achieved within a trial's duration, based on published trial data and to present a formalized meta-analysis of modeled outcome postponement for all-cause mortality in statin trials. METHODS The outcome postponement was modeled on the basis of the hazard ratio or relative risk, the mortality rate in the placebo group and the trial's duration. Outcome postponement was subjected to a meta-analysis. We also estimated the average outcome postponement as the area between Kaplan-Meier curves. Statin trials were identified through a systematic review. RESULTS The median modeled outcome postponement was 10.0 days (interquartile range, 2.9-19.5 days). Meta-analysis of 16 trials provided a summary estimate of outcome postponement for all-cause mortality of 12.6 days, with a 95% postponement interval (PI) of 7.1-18.0. For primary, secondary, and mixed prevention trials, respectively, outcome postponements were 10.2 days (PI, 4.0-16.3), 17.4 days (PI, 6.0-28.8), and 8.5 days (PI, 1.9-15.0). CONCLUSIONS The modeled outcome postponement is amenable to meta-analysis and may be a useful approach for presenting the benefits of preventive interventions. Statin treatment results in a small increase of average survival within the duration of a trial. SYSTEMATIC REVIEW REGISTRATION The systematic review was registered in PROSPERO [CRD42016037507] .
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Jaspers NEM, Visseren FLJ, Numans ME, Smulders YM, van Loenen Martinet FA, van der Graaf Y, Dorresteijn JAN. Variation in minimum desired cardiovascular disease-free longevity benefit from statin and antihypertensive medications: a cross-sectional study of patient and primary care physician perspectives. BMJ Open 2018; 8:e021309. [PMID: 29804065 PMCID: PMC5988148 DOI: 10.1136/bmjopen-2017-021309] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/27/2018] [Accepted: 03/29/2018] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE Expressing therapy benefit from a lifetime perspective, instead of only a 10-year perspective, is both more intuitive and of growing importance in doctor-patient communication. In cardiovascular disease (CVD) prevention, lifetime estimates are increasingly accessible via online decision tools. However, it is unclear what gain in life expectancy is considered meaningful by those who would use the estimates in clinical practice. We therefore quantified lifetime and 10-year benefit thresholds at which physicians and patients perceive statin and antihypertensive therapy as meaningful, and compared the thresholds with clinically attainable benefit. DESIGN Cross-sectional study. SETTINGS (1) continuing medical education conference in December 2016 for primary care physicians;(2) information session in April 2017 for patients. PARTICIPANTS 400 primary care physicians and 523 patients in the Netherlands. OUTCOME Months gain of CVD-free life expectancy at which lifelong statin therapy is perceived as meaningful, and months gain at which 10 years of statin and antihypertensive therapy is perceived as meaningful. Physicians were framed as users for lifelong and prescribers for 10-year therapy. RESULTS Meaningful benefit was reported as median (IQR). Meaningful lifetime statin benefit was 24 months (IQR 23-36) in physicians (as users) and 42 months (IQR 12-42) in patients willing to consider therapy. Meaningful 10-year statin benefit was 12 months (IQR 10-12) for prescribing (physicians) and 14 months (IQR 10-14) for using (patients). Meaningful 10-year antihypertensive benefit was 12 months (IQR 8-12) for prescribing (physicians) and 14 months (IQR 10-14) for using (patients). Women desired greater benefit than men. Age, CVD status and co-medication had minimal effects on outcomes. CONCLUSION Both physicians and patients report a large variation in meaningful longevity benefit. Desired benefit differs between physicians and patients and exceeds what is clinically attainable. Clinicians should recognise these discrepancies when prescribing therapy and implement individualised medicine and shared decision-making. Decision tools could provide information on realistic therapy benefit.
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Affiliation(s)
- Nicole E M Jaspers
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mattijs E Numans
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Yvo M Smulders
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Yolanda van der Graaf
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
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Brand PLP, van Dulmen S. Can we trust what parents tell us? A systematic review. Paediatr Respir Rev 2017; 24:65-71. [PMID: 28283301 DOI: 10.1016/j.prrv.2017.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 01/20/2017] [Indexed: 12/11/2022]
Abstract
Taking a history is a key diagnostic instrument in paediatric consultations. Numerous issues potentially reduce the history's reliability. Therefore, paediatricians have always expressed ambivalence regarding history taking from parents, both valuing and distrusting it. In this review, we describe how parents build and present a description of their child's health issues in the conceptual framework of self-regulation theory. We performed a systematic review on the literature on the reliability of history taking. No studies examined the reliability of history taking from parents, but there is a considerable body of evidence on the issue of mutual trust in relationships between health care professionals and patients. Because trust is a dynamic relational phenomenon, taking a patient centred approach in consultations is likely to increase the patients' and parents' trust in the health care professional, and their willingness to follow the health care professional's treatment proposals. We provide evidence based recommendations on how to build and maintain trust in paediatric consultations by taking a patient centred approach in such consultations.
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Affiliation(s)
- Paul L P Brand
- Isala Women's and Children's Hospital, Zwolle, the Netherlands; UMCG Postgraduate School of Medicine, University Medical Centre and University of Groningen, Groningen, the Netherlands.
| | - Sandra van Dulmen
- Dept. of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands; NIVEL (Netherlands institute for health services research), Utrecht, the Netherlands; Faculty of Health Sciences, University College of Southeast Norway, Drammen, Norway
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Coon SA, Ashjian EJ, Herink MC. Current Use of Statins for Primary Prevention of Cardiovascular Disease: Patient-Reported Outcomes and Adherence. CURRENT CARDIOVASCULAR RISK REPORTS 2016. [DOI: 10.1007/s12170-016-0504-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Barfoed BL, Paulsen MS, Christensen PM, Halvorsen PA, Jarbøl DE, Larsen ML, Munch MR, Søndergaard J, Nielsen JB. Associations between patients' adherence and GPs' attitudes towards risk, statin therapy and management of non-adherence--a survey and register-based study. Fam Pract 2016; 33:140-7. [PMID: 26936208 DOI: 10.1093/fampra/cmw005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Previous studies suggest that doctors' personal lifestyle, risk taking personality and beliefs about risk reducing therapies may affect their clinical decision-making. Whether such factors are further associated with patients' adherence with medication is largely unknown. OBJECTIVE To estimate associations between GPs' attitudes towards risk, statin therapy and management of non-adherence and their patients' adherence, and to identify subgroups of GPs with poor patient adherence. METHODS All Danish GPs were invited to participate in an online survey. We asked whether they regarded statin treatment as important, how they managed non-adherence and whether non-adherence annoyed them. The Jackson Personality Inventory-revised was used to measure risk attitude. The GPs' responses were linked to register data on their patients' redeemed statin prescriptions. Mixed effect logistic regression was used to estimate associations between patient adherence and GPs' attitudes. Adherence was estimated by the proportion of days covered in a 1-year period using an 80% cut-off. RESULTS We received responses from 1398 GPs (42.2%) who initiated statin therapy in 12 192 patients during the study period. In total 6590 (54.1%) of these patients were adherent. Patients who had GPs rarely assessing their treatment adherence were less likely to be adherent than those who had GPs assessing their patients' treatment adherence now and then, odds ratio (OR) 0.86 [confidence interval (CI) 0.77-0.96]. No other associations were found between patients' adherence and GPs' attitudes. CONCLUSIONS Our findings suggest that GPs' attitudes to risk, statin therapy or management of non-adherence are not significantly associated with their patients' adherence.
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Affiliation(s)
- Benedicte L Barfoed
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark,
| | - Maja S Paulsen
- Danish Quality Unit of General Practice, Odense, Denmark
| | | | - Peder A Halvorsen
- Department of Community Medicine, University of Tromsø, The Arctic University of Norway, Tromsø, Norway and
| | - Dorte E Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Mogens L Larsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Maria R Munch
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper B Nielsen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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